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    First Nations peoples leading the way in COVID‐19 pandemic planning, response and management

    Kristy Crooks, Dawn Casey and James S Ward
    Med J Aust 2020; 213 (4): . || doi: 10.5694/mja2.50704
    Published online: 17 August 2020

    Engaging First Nations peoples in public health emergencies is critical to reducing health inequities

    Aboriginal and Torres Strait Islander (respectfully hereafter First Nations) peoples of Australia have experienced poorer health outcomes than the rest of the Australian population during recent pandemics.1,2 In 2009, during the H1N1 influenza pandemic, diagnosis rates, hospitalisations and intensive care unit admissions occurred at five, eight and three times, respectively, the rates recorded among non‐Indigenous people.1,2,3

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    • 1 Menzies School of Health Research, Charles Darwin University, Darwin, NT
    • 2 National Aboriginal Community Controlled Health Organisation, Canberra, ACT
    • 3 University of Queensland, Brisbane, QLD


    Acknowledgements: 

    We acknowledge the traditional custodians of the land and waters on which we live and work as the First Peoples of Australia. We are members of the Aboriginal and Torres Strait Islander Advisory Group on COVID‐19 and we acknowledge and thank all members of the Advisory Group for their continued work and commitment in advocating for cultural inclusion and providing space for First Nations peoples to have a voice in pandemic planning, response and management.

    Competing interests:

    No relevant disclosures.

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      Unemployment, suicide and COVID‐19: using the evidence to plan for prevention

      Mark Deady, Leona Tan, Nathasha Kugenthiran, Daniel Collins, Helen Christensen and Samuel B Harvey
      Med J Aust 2020; 213 (4): . || doi: 10.5694/mja2.50715
      Published online: 3 August 2020

      COVID‐19‐related unemployment may significantly increase suicide rates; implementation of appropriate preventive measures is critical

      In response to the coronavirus disease 2019 (COVID‐19) pandemic, the imposition of social distancing policies and related labour market impacts have resulted in extensive job losses. Globally, the International Monetary Fund has predicted the steepest economic downturn since the Great Depression.1 In May 2020, 2.3 million Australians (one in five employed people) were either unemployed or had work hours reduced for economic reasons, resulting in the steepest rise in rates of unemployment on record — a change from 5.2% in March to 7.1%2 — with Treasury predicting a rate of 8% by September 2020.

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      • 1 Black Dog Institute, UNSW, Sydney, NSW
      • 2 UNSW, Sydney, NSW


      Correspondence: m.deady@unsw.edu.au
      Acknowledgements: 

      Mark Deady, Leona Tan and Samuel Harvey are funded by an icare Foundation grant. Samuel Harvey is also supported by a National Health and Medical Research Council (NHMRC) investigator grant (No. 1178666). The authors are additionally supported by the NHMRC Centre for Research Excellence in Suicide Prevention. The funding institutions had no role in the planning, writing or publication of this work.

      Competing interests:

      No relevant disclosures.

      • 1. International Monetary Fund. World Economic Outlook, April 2020: the Great Lockdown. Chapter 1: Global prospects and policies. Washington: International Monetary Fund; 2020. https://www.imf.org/en/Publications/WEO/Issues/2020/04/14/weo-april-2020#Chapter%201 (viewed July 2020).
      • 2. Australian Bureau of Statistics. Labour force, Australia, May 2020 [6202.0] Canberra: ABS, 2020. https://www.abs.gov.au/ausstats/abs@.nsf/mf/6202.0 (viewed June 2020).
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      • 8. Chang SS, Gunnell D, Sterne JA, et al. Was the economic crisis 1997–1998 responsible for rising suicide rates in East/Southeast Asia? A time‐trend analysis for Japan, Hong Kong, South Korea, Taiwan, Singapore and Thailand. Soc Sci Med 2009; 68: 1322–1331.
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      • 10. Australian Medical Association. Joint statement: COVID‐19 impact likely to lead to increased rates of suicide and mental illness [press release]. 7 May 2020. https://ama.com.au/media/joint-statement-covid-19-impact-likely-lead-increased-rates-suicide-and-mental-illness (viewed July 2020).
      • 11. Field G. Nights underground in darkest London: the Blitz, 1940–1941. Int Labor Work Class Hist 2002; 62: 11–49.
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      • 15. Torok M, Han J, Baker S, et al. Suicide prevention using self‐guided digital interventions: a systematic review and meta‐analysis of randomised controlled trials. Lancet Digit Health 2020; 2: e25–e36.
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      • 17. Torok M, Konings P, Batterham PJ, Christensen H. Spatial clustering of fatal, and non‐fatal, suicide in New South Wales, Australia: implications for evidence‐based prevention. BMC Psychiatry 2017; 17: 339.

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        Recruiting and retaining general practitioners in rural practice: systematic review and meta‐analysis of rural pipeline effects

        Jessica Ogden, Scott Preston, Riitta L Partanen, Remo Ostini and Peter Coxeter
        Med J Aust 2020; 213 (5): . || doi: 10.5694/mja2.50697
        Published online: 3 August 2020

        Abstract

        Objective: To synthesise quantitative data on the effects of rural background and experience in rural areas during medical training on the likelihood of general practitioners practising and remaining in rural areas.

        Study design: Systematic review and meta‐analysis of the effects of rural pipeline factors (rural background; rural clinical and education experience during undergraduate and postgraduate/vocational training) on likelihood of later general practice in rural areas.

        Data sources: MEDLINE (Ovid), EMBASE, Informit Health Collection, and ERIC electronic database records published to September 2018; bibliographies of retrieved articles; grey literature.

        Data synthesis: Of 6709 publications identified by our search, 27 observational studies were eligible for inclusion in our systematic review; when appropriate, data were pooled in random effects models for meta‐analysis. Study quality, assessed with the Newcastle–Ottawa scale, was very good or good for 24 studies, satisfactory for two, and unsatisfactory for one. Meta‐analysis indicated that GPs practising in rural communities was significantly associated with having a rural background (odds ratio [OR], 2.71; 95% CI, 2.12–3.46; ten studies) and with rural clinical experience during undergraduate (OR, 1.75; 95% CI, 1.48–2.08; five studies) and postgraduate training (OR, 4.57; 95% CI, 2.80–7.46; eight studies).

        Conclusion: GPs with rural backgrounds or rural experience during undergraduate or postgraduate medical training are more likely to practise in rural areas. The effects of multiple rural pipeline factors may be cumulative, and the duration of an experience influences the likelihood of a GP commencing and remaining in rural general practice. These findings could inform government‐led initiatives to support an adequate rural GP workforce.

        Protocol registration: PROSPERO, CRD42017074943 (updated 1 February 2018).

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        • 1 General Practice Training Queensland, Brisbane, QLD
        • 2 Rural Clinical School, University of Queensland, Hervey Bay, QLD
        • 3 Rural Clinical School, University of Queensland, Toowoomba, QLD


        Correspondence: spreston@gptq.qld.edu.au
        Competing interests:

        No relevant disclosures.

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          Unintended consequences of using real time prescription monitoring systems

          Sarah Haines, Michael Savic, Louisa Picco, Suzanne Nielsen and Adrian Carter
          Med J Aust 2020; 213 (3): . || doi: 10.5694/mja2.50616
          Published online: 3 August 2020

          To the Editor: More Australians die of prescription medication overdose than of illicit drug use or motor vehicle accidents.1 Real time prescription monitoring systems have been recommended to track patients’ supply history for potentially high risk medicines, including strong opioids and benzodiazepines. These programs aim to assist in the early identification of high risk medicine use to inform clinical care, and have received broad support from pharmacy and medical professional groups.


          • 1 Turner Institute for Brain and Mental Health, Monash University, Melbourne, VIC
          • 2 Turning Point, Eastern Health and Monash University, Melbourne, VIC
          • 3 Monash Addiction Research Centre, Monash University, Melbourne, VIC


          Correspondence: Sarah.Haines@monash.edu
          Competing interests:

          No relevant disclosures.

          • 1. Department of Health and Human Services. Regulatory impact statement — proposed drugs, poisons and controlled substances amendment (real‐time prescription monitoring). Melbourne: Victoria State Government, 2018. https://www2.health.vic.gov.au/about/publications/ResearchAndReports/rtpm-regulatory-impact-statement (viewed Apr 2020).
          • 2. Fink DS, Schleimer JP, Sarvet A, et al. Association between prescription drug monitoring programs and nonfatal and fatal drug overdoses: a systematic review. Ann Intern Med 2018; 168: 783–790.
          • 3. James JR, Scott JM, Klein JW, et al. Mortality after discontinuation of primary care‐based chronic opioid therapy for pain: a retrospective cohort study. J Gen Intern Med 2019; 34: 2749–2755.
          • 4. Tsai AC, Kiang MV, Barnett ML, et al. Stigma as a fundamental hindrance to the United States opioid overdose crisis response. PLoS Med 2019; 16: e1002969.
          • 5. Bauer M, Monteith S, Geddes J, et al. Automation to optimise physician treatment of individual patients: examples in psychiatry. Lancet Psychiatry 2019; 6: 338–349.

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            Reusing N95 (or P2) masks: current evidence and urgent research questions

            James M Branley, Adam Polkinghorne and Gwendolyn L Gilbert
            Med J Aust 2020; 213 (3): . || doi: 10.5694/mja2.50694
            Published online: 3 August 2020

            To the Editor: The coronavirus disease 2019 (COVID‐19) pandemic is placing increasing pressure on the health care resources of nations. Particular concern is held for supplies of N95 (or P2) masks and surgical masks — personal protective equipment designed to achieve close facial fit and protection from more than 95% of 0.3 μm test particles. These masks are recommended for routine care of patients on airborne precautions, with current guidelines indicating that N95 masks are single use.1 Further highlighting the importance of N95 masks in protecting health care workers during the COVID‐19 pandemic, a recent study of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV2) infection rates among medical staff in Zhongnan Hospital of Wuhan University showed that none of the staff (0/278) who wore N95 masks and followed frequent disinfection and handwashing became infected during the period of 2–22 January 2020 compared with 4.7% (10/231) of staff who did not wear masks, despite the fact that the latter group worked in lower risk areas.2

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            • 1 Nepean Hospital, Sydney, NSW
            • 2 University of Sydney, Sydney, NSW
            • 3 Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Sydney, NSW


            Competing interests:

            No relevant disclosures.

            • 1. National Health and Medical Research Council. Australian guidelines for the prevention and control of infection in healthcare (2019). Canberra: NHMRC, 2019. https://nhmrc.govcms.gov.au/about-us/publications/australian-guidelines-prevention-and-control-infection-healthcare-2019 (viewed June 2020).
            • 2. Wang X, Pan Z, Cheng Z. Association between 2019‐nCoV transmission and N95 respirator use. J Hosp Infect 2020; 105: 104–105.
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            • 4. Beckman S, Materna B, Goldmacher S, et al. Evaluation of respiratory protection programs and practices in California hospitals during the 2009–2010 H1N1 influenza pandemic. Am J Infect Control 2013; 41: 1024–1031.
            • 5. Mills D, Harnish DA, Lawrence C, et al. Ultraviolet germicidal irradiation of influenza‐contaminated N95 filtering facepiece respirators. Am J Infect Control 2018; 46: e49–e55.
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            • 13. Coulliette AD, Perry KA, Fisher EM, et al. MS2 coliphage as a surrogate for 2009 pandemic influenza A (H1N1) virus (pH1N1) in surface survival studies on N95 filtering facepiece respirators. J Int Soc Respir Prot 2014; 21: 14–22.

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              Management of adult cardiac arrest in the COVID‐19 era: consensus statement from the Australasian College for Emergency Medicine

              Simon Craig, Mya Cubitt, Ashish Jaison, Steven Troupakis, Natalie Hood, Christina Fong, Adnan Bilgrami, Peter Leman, Juan Carlos Ascencio‐Lane, Guruprasad Nagaraj, John Bonning, Gabriel Blecher, Rob Mitchell, Ellen Burkett, Sally M McCarthy, Amanda M Rojek, Kim Hansen, Helen Psihogios, Peter Allely, Simon Judkins, Lai Heng Foong, Stephen Bernard and Peter A Cameron
              Med J Aust 2020; 213 (3): . || doi: 10.5694/mja2.50699
              Published online: 3 August 2020

              Abstract

              Introduction: The global pandemic of coronavirus disease 2019 (COVID‐19) has caused significant worldwide disruption. Although Australia and New Zealand have not been affected as much as some other countries, resuscitation may still pose a risk to health care workers and necessitates a change to our traditional approach. This consensus statement for adult cardiac arrest in the setting of COVID‐19 has been produced by the Australasian College for Emergency Medicine (ACEM) and aligns with national and international recommendations.

              Main recommendations:

              • In a setting of low community transmission, most cardiac arrests are not due to COVID‐19.
              • Early defibrillation saves lives and is not considered an aerosol generating procedure.
              • Compression‐only cardiopulmonary resuscitation is thought to be a low risk procedure and can be safely initiated with the patient's mouth and nose covered.
              • All other resuscitative procedures are considered aerosol generating and require the use of airborne personal protective equipment (PPE).
              • It is important to balance the appropriateness of resuscitation against the risk of infection.
              • Methods to reduce nosocomial transmission of COVID‐19 include a physical barrier such as a towel or mask over the patient's mouth and nose, appropriate use of PPE, minimising the staff involved in resuscitation, and use of mechanical chest compression devices when available.
              • If COVID‐19 significantly affects hospital resource availability, the ethics of resource allocation must be considered.

               

              Changes in management: The changes outlined in this document require a significant adaptation for many doctors, nurses and paramedics. It is critically important that all health care workers have regular PPE and advanced life support training, are able to access in situ simulation sessions, and receive extensive debriefing after actual resuscitations. This will ensure safe, timely and effective management of the patients with cardiac arrest in the COVID‐19 era.

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              • 1 Monash Health, Melbourne, VIC
              • 2 Monash University, Melbourne, VIC
              • 3 Royal Melbourne Hospital, Melbourne, VIC
              • 4 Centre for Integrated Critical Care, University of Melbourne, Melbourne, VIC
              • 5 Emergency and Trauma Centre, Alfred Health, Melbourne, VIC
              • 6 Epworth HealthCare, Melbourne, VIC
              • 7 Surf Life Saving Australia, Sydney, NSW
              • 8 Fiona Stanley Hospital, Perth, WA
              • 9 University of Western Australia, Perth, WA
              • 10 Royal Hobart Hospital, Hobart, TAS
              • 11 University of Tasmania, Hobart, TAS
              • 12 South Western Emergency Research Institute, Liverpool Hospital, Sydney, NSW
              • 13 University of New South Wales, Sydney, NSW
              • 14 Australasian College for Emergency Medicine, Melbourne, VIC
              • 15 Council of Medical Colleges of Aotearoa New Zealand, Wellington, New Zealand
              • 16 Monash Medical Centre, Melbourne, VIC
              • 17 Princess Alexandra Hospital, Brisbane, QLD
              • 18 Clinical Excellence Queensland, Brisbane, QLD
              • 19 Prince of Wales Hospital and Community Health Services, Sydney, NSW
              • 20 Centre for Integrated Critical Care, University of Melbourne, Melbourne, VIC
              • 21 St Andrew's War Memorial Hospital, Brisbane, QLD
              • 22 Prince Charles Hospital, Brisbane, QLD
              • 23 Sir Charles Gairdner Hospital, Perth, WA
              • 24 Austin Hospital, Melbourne, VIC
              • 25 Bankstown–Lidcombe Hospital, Sydney, NSW
              • 26 University of Western Sydney, Sydney, NSW
              • 27 Centre for Research and Evaluation, Ambulance Victoria, Melbourne, VIC


              Acknowledgements: 

              The authors would like to acknowledge the assistance of the following ACEM staff in the production of this consensus statement: Robert Lee, Nicola Ballenden, Andrea Johnston and Belinda Rule.

              Competing interests:

              No relevant disclosures.

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                Clinical trials for the prevention and treatment of COVID‐19: current state of play

                Joshua S Davis, David Ferreira, Justin T Denholm and Steven YC Tong
                Med J Aust 2020; 213 (2): . || doi: 10.5694/mja2.50673
                Published online: 20 July 2020

                Summary

                • Since coronavirus disease 2019 (COVID‐19) emerged in Wuhan, China in December 2019 and spread around the world, over 1100 clinical studies have been registered globally on clinical trials registries, including over 500 randomised controlled trials.
                • Such rapid development and launch of clinical trials is impressive but presents challenges, including the potential for duplication and competition.
                • There is currently no known effective treatment for COVID‐19.
                • In order to focus on those studies most likely to influence clinical practice, we summarise the 31 currently registered randomised trials with a target sample size of at least 1000 participants.
                • We have grouped these trials into four categories: prophylaxis; treatment of outpatients with mild COVID‐19; treatment of hospitalised patients with moderate COVID‐19; and treatment of hospitalised patients with moderate or severe disease.
                • The most common therapeutic agent being trialled currently is hydroxychloroquine (24 trials with potential sample size of over 25 000 participants), followed by lopinavir–ritonavir (seven trials) and remdesevir (five trials)
                • There are many candidate drugs in pre‐clinical and early phase development, and these form a pipeline for future large clinical trials if current candidate therapies prove ineffective or unsafe.

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                • 1 Menzies School of Health Research, Darwin, NT
                • 2 John Hunter Hospital, Newcastle, NSW
                • 3 Royal Melbourne Hospital, Melbourne, VIC
                • 4 University of Melbourne, Melbourne, VIC
                • 5 Peter Doherty Institute for Infection and Immunity, Melbourne, VIC


                Correspondence: joshua.davis@menzies.edu.au
                Competing interests:

                No relevant disclosures.

                • 1. US Centers for Disease Control and Prevention. Outbreak of severe acute respiratory syndrome–worldwide, 2003. MMWR Morb Mortal Wkly Rep 2003; 52: 226–228.
                • 2. Wise J. Patient with new strain of coronavirus is treated in intensive care at London hospital. BMJ 2012; 345: e6455.
                • 3. Dawood FS, Jain S, Finelli L, et al. Emergence of a novel swine‐origin influenza A (H1N1) virus in humans. N Engl J Med 2009; 360: 2605–2615.
                • 4. Momattin H, Al‐Ali AY, Al‐Tawfiq JA. A systematic review of therapeutic agents for the treatment of the Middle East respiratory syndrome coronavirus (MERS‐CoV). Travel Med Infect Dis 2019; 30: 9–18.
                • 5. Yao T‐T, Qian J‐D, Zhu W‐Y, Wang Y, et al. A systematic review of lopinavir therapy for SARS coronavirus and MERS coronavirus – a possible reference for coronavirus disease‐19 treatment option. J Med Virol 2020; 92: 556–563.
                • 6. Yao X, Ye F, Zhang M, et al. In vitro antiviral activity and projection of optimized dosing design of hydroxychloroquine for the treatment of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). Clin Infect Dis 2020; https://doi.org/10.1093/cid/ciaa237 [Epub ahead of print].
                • 7. Costanzo M, De Giglio MAR, Roviello GN. SARS CoV‐2: recent reports on antiviral therapies based on lopinavir/ritonavir, darunavir/umifenovir, hydroxychloroquine, remdesivir, favipiravir and other drugs for the treatment of the new coronavirus. Curr Med Chem 2020; https://doi.org/10.2174/0929867327666200416131117 [Epub ahead of print].
                • 8. Liu B, Li M, Zhou Z, Guan X, et al. Can we use interleukin‐6 (IL‐6) blockade for coronavirus disease 2019 (COVID‐19)‐induced cytokine release syndrome (CRS)? J Autoimmun 2020; https://doi.org/10.1016/j.jaut.2020.102452 [Epub ahead of print].
                • 9. Dunning JW, Merson L, Rohde GGU, et al. Open source clinical science for emerging infections. Lancet Infect Dis 2014; 14: 8–9.
                • 10. Bi Q, Wu Y, Mei S, Ye C, et al. Epidemiology and transmission of COVID‐19 in Shenzhen, China: analysis of 391 cases and 1286 of their close contacts. Lancet Infect Dis 2020; https://doi.org/10.1016/s1473-3099(20)30287-5 [Epub ahead of print].
                • 11. Zimmermann P, Finn A, Curtis N. Does BCG vaccination protect against nontuberculous mycobacterial infection? a systematic review and meta‐analysis. J Infect Dis 2018; 218: 679–687.
                • 12. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID‐19) outbreak in China: summary of a report of 72314 cases from the Chinese Center for Disease Control and Prevention. JAMA 2020; https://doi.org/10.1001/jama.2020.2648 [Epub ahead of print].
                • 13. Woodcock J, LaVange LM. Master protocols to study multiple therapies, multiple diseases, or both. N Engl J Med 2017; 377: 62–70.
                • 14. Angus DC, Berry S, Lewis RJ, et al. The Randomized Embedded Multifactorial Adaptive Platform for Community‐acquired Pneumonia (REMAP‐CAP) study: rationale and design. Ann Am Thorac Soc 2020; https://doi.org/10.1513/annalsats.202003-192sd [Epub ahead of print].
                • 15. Gordon CJ, Tchesnokov EP, Feng JY, et al. The antiviral compound remdesivir potently inhibits RNA‐dependent RNA polymerase from Middle East respiratory syndrome coronavirus. J Biol Chem 2020; 295: 4773–4779.
                • 16. Sheahan TP, Sims AC, Leist SR, et al. Comparative therapeutic efficacy of remdesivir and combination lopinavir, ritonavir, and interferon beta against MERS‐CoV. Nat Commun 2020; 11: 222.
                • 17. Tchesnokov EP, Feng JY, Porter DP, Gotte M. Mechanism of inhibition of Ebola virus RNA‐dependent RNA polymerase by remdesivir. Viruses 2019; 11: 326.
                • 18. Cao B, Wang Y, Wen D, et al. A trial of lopinavir‐ritonavir in adults hospitalized with severe Covid‐19. N Engl J Med 2020; 382: 1787–1799.
                • 19. Gautret P, Lagier JC, Parola P, et al. Hydroxychloroquine and azithromycin as a treatment of COVID‐19: results of an open‐label non‐randomized clinical trial. Int J Antimicrob Agents 2020; https://doi.org/10.1016/j.ijantimicag.2020.105949 [Epub ahead of print].

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                  New Australian birthweight centiles

                  Farmey A Joseph, Jonathan A Hyett, Philip J Schluter, Andrew McLennan, Adrienne Gordon, Georgina M Chambers, Lisa Hilder, Stephanie KY Choi and Bradley Vries
                  Med J Aust 2020; 213 (2): . || doi: 10.5694/mja2.50676
                  Published online: 20 July 2020

                  Abstract

                  Objectives: To prepare more accurate population‐based Australian birthweight centile charts by using the most recent population data available and by excluding pre‐term deliveries by obstetric intervention of small for gestational age babies.

                  Design: Population‐based retrospective observational study.

                  Setting: Australian Institute of Health and Welfare National Perinatal Data Collection.

                  Participants: All singleton births in Australia of 23–42 completed weeks’ gestation and with spontaneous onset of labour, 2004–2013. Births initiated by obstetric intervention were excluded to minimise the influence of decisions to deliver small for gestational age babies before term.

                  Main outcome measures: Birthweight centile curves, by gestational age and sex.

                  Results: Gestational age, birthweight, sex, and labour onset data were available for 2 807 051 singleton live births; onset of labour was spontaneous for 1 582 137 births (56.4%). At pre‐term gestational ages, the 10th centile was higher than the corresponding centile in previous Australian birthweight charts based upon all births.

                  Conclusion: Current birthweight centile charts probably underestimate the incidence of intra‐uterine growth restriction because obstetric interventions for delivering pre‐term small for gestational age babies depress the curves at earlier gestational ages. Our curves circumvent this problem by excluding intervention‐initiated births; they also incorporate more recent population data. These updated centile curves could facilitate more accurate diagnosis of small for gestational age babies in Australia.

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                  • 1 Royal Prince Alfred Hospital, Sydney, NSW
                  • 2 Sydney Institute for Women, Children and their Families, Sydney, NSW
                  • 3 Sydney Medical School, University of Sydney, Sydney, NSW
                  • 4 University of Canterbury, Christchurch, New Zealand
                  • 5 University of Queensland, Brisbane, QLD
                  • 6 Charles Perkins Centre, University of Sydney, Sydney, NSW
                  • 7 National Perinatal Epidemiology and Statistics Unit, University of New South Wales, Sydney, NSW
                  • 8 Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW


                  Correspondence: farmey@alum.mit.edu
                  Acknowledgements: 

                  We acknowledge the Ministries of Health of all Australian states and territories for providing data to the National Perinatal Data Collection. We also acknowledge the Australian Institute of Health and Welfare (AIHW) for preparing and providing the National Perinatal Data Collection data for this study. We are grateful to the Victorian Consultative Council on Obstetric and Paediatric Mortality and Morbidity (CCOPMM) for providing access to the de‐identified data from the Victorian Perinatal Data Collection that contributes to the AIHW National Perinatal Data Collection and for the assistance of the staff at the Consultative Councils Unit, Safer Care Victoria, for facilitating the Victorian approval process for this project. The views expressed in this article do not necessarily reflect those of CCOPMM. Finally, we thank Kevin McGeechan for his advice on statistical analysis.

                  Competing interests:

                  No relevant disclosures.

                  • 1. Doctor BA, O'Riordan MA, Kirchner HL, et al. Perinatal correlates and neonatal outcomes of small for gestational age infants born at term gestation. Am J Obstet Gynecol 2001; 185: 652–659.
                  • 2. Strauss RS. Adult functional outcome of those born small for gestational age. JAMA 2000; 283: 625–632.
                  • 3. Rao SC, Tompkins J; World Health Organization. Growth curves for preterm infants. Early Hum Dev 2007; 83: 643–651.
                  • 4. Reeves S, Bernstein IM. Optimal growth modeling. Semin Perinatol 2008; 32: 148–153.
                  • 5. Hoftiezer L, Hukkelhoven CWPM, Hogeveen M, et al. Defining small‐for‐gestational‐age: prescriptive versus descriptive birthweight standards. Eur J Pediatr 2016; 175: 1047–1057.
                  • 6. Hadlock F, Harrist R, Martinez‐Poyer J. In utero analysis of fetal growth: a sonographic weight standard. Radiology 1991; 181: 129–133.
                  • 7. Papageorghiou AT, Ohuma EO, Altman DG, et al; International Fetal and Newborn Growth Consortium for the 21st Century (INTERGROWTH‐21st). International standards for fetal growth based on serial ultrasound measurements: the Fetal Growth Longitudinal Study of the INTERGROWTH‐21st Project. Lancet 2014; 384: 869–879.
                  • 8. Dobbins TA, Sullivan EA, Roberts CL, Simpson JM. Australian national birthweight percentiles by sex and gestational age, 1998–2007. Med J Aust 2012; 197: 291–294. https://www.mja.com.au/journal/2012/197/5/australian-national-birthweight-percentiles-sex-and-gestational-age-1998-2007
                  • 9. Sarris I, Ioannou C, Ohuma EO, et al; International Fetal and Newborn Growth Consortium for the 21st Century. Standardisation and quality control of ultrasound measurements taken in the INTERGROWTH‐21st Project. BJOG 2013; 120: 33–37.
                  • 10. Dudley NJ. A systematic review of the ultrasound estimation of fetal weight. Ultrasound Obstet Gynecol 2005; 25: 80–89.
                  • 11. Burkhardt T, Schäffer L, Zimmermann R, Kurmanavicius J. Newborn weight charts underestimate the incidence of low birthweight in preterm infants. Am J Obstet Gynecol 2008; 199: 139.e1–139.e6.
                  • 12. Hutcheon JA, Platt RW. The missing data problem in birth weight percentiles and thresholds for ‘“small‐ for‐gestational‐age”. Am J Epidemiol 2008; 167: 786–792.
                  • 13. Joseph FA, Hyett JA, McGeechan K, et al. A new approach to developing birth weight reference charts: a retrospective observational study. Fetal Diagn Ther 2018; 43: 148–155.
                  • 14. Australian Institute of Health and Welfare. Australia's mothers and babies 2016: in brief (Cat. no. PER 97; Perinatal statistics series no. 34). Canberra: AIHW, 2018.
                  • 15. von Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. PLoS Med 2007; 4: e296.
                  • 16. Daniel‐Spiegel E, Weiner E, Yarom I, et al. Establishment of fetal biometric charts using quantile regression analysis. J Ultrasound Med 2013; 32: 23–33.
                  • 17. Hoaglin DC, John W. Tukey and data analysis. Stat Sci 2003; 18: 311–318.
                  • 18. Fenton TR, Kim JH. A systematic review and meta‐analysis to revise the Fenton growth chart for preterm infants. BMC Pediatr 2013; 13: 59.
                  • 19. Hoftiezer L, Hof MHP, Dijs‐Elsinga J, et al. From population reference to national standard: new and improved birthweight charts. Am J Obstet Gynecol 2019; 220: 383.e1–383.e17.
                  • 20. Villar J, Cheikh Ismail L, Victora CG, et al; International Fetal and Newborn Growth Consortium for the 21st Century (INTERGROWTH‐21st). International standards for newborn weight, length, and head circumference by gestational age and sex: the Newborn Cross‐Sectional Study of the INTERGROWTH‐21st Project. Lancet 2014; 384: 857–868.
                  • 21. Wei Y, Pere A, Koenker R, He X. Quantile regression methods for reference growth charts. Stat Med 2006; 25: 1369–1382.
                  • 22. Goldenberg RL, Culhane JF, Iams JD, Romero R. Epidemiology and causes of preterm birth. Lancet 2008; 371: 75–84.
                  • 23. Bastek JA, Gómez LM, Elovitz MA. The role of inflammation and infection in preterm birth. Clin Perinatol 2011; 38: 385–406.
                  • 24. Kim CJ, Romero R, Chaemsaithong P, et al. Acute chorioamnionitis and funisitis: definition, pathologic features, and clinical significance. Am J Obstet Gynecol 2015; 213 (4 Suppl): S29–S52.
                  • 25. Zeitlin J, Ancel PY, Saurel‐Cubizollles MJ, Papiernik E. The relationship between intrauterine growth restriction and preterm delivery: an empirical approach using data from a European case–control study. BJOG 2000; 107: 750–758.
                  • 26. Park FJ, de Vries B, Hyett JA, Gordon A. Epidemic of large babies highlighted by use of INTERGROWTH21st international standard. Aust New Zeal J Obstet Gynaecol 2018; 58: 506–553.

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                    The role of cost‐effectiveness analyses in investment decision making by primary health networks

                    Sally Hall Dykgraaf and Amanda Barnard
                    Med J Aust 2020; 213 (2): . || doi: 10.5694/mja2.50689
                    Published online: 20 July 2020

                    Scientific rigour and pragmatic implementation are both required, combining research findings with other forms of evidence

                    Primary health networks (PHNs) have been part of the health landscape in Australia since July 2015. Following the Horvath review of Medicare Locals,1 they were established as locally configured organisations that could support primary health care service providers, design and deliver improved primary health care, and work with hospitals to maximise the efficiency, effectiveness and coordination of care. One key role for PHNs is to commission primary health care services that meet local needs and improve outcomes by procuring services from third party providers, applying market‐making and supply‐shaping principles.2 To do this, PHNs undertake population‐level needs analyses to identify service gaps, reduce hospital burden, and promote value for money. They also help general practices and other primary health care providers deliver community care, optimise quality and safety, and make meaningful use of electronic support systems.


                    • Rural Clinical School, Australian National University, Canberra, ACT


                    Correspondence: Sally.Hall@anu.edu.au
                    Acknowledgements: 

                    We thank Dianne Kitcher (chief executive officer, COORDINARE) for her insights and comments on the draft manuscript.

                    Competing interests:

                    Amanda Barnard is a board director and chair of the Southern NSW Clinical Council of COORDINARE (South Eastern NSW primary health network).

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                      Hyperendemic rheumatic heart disease in a remote Australian town identified by echocardiographic screening

                      Joshua R Francis, Helen Fairhurst, Hilary Hardefeldt, Shannon Brown, Chelsea Ryan, Kurt Brown, Greg Smith, Roz Baartz, Ari Horton, Gillian Whalley, James Marangou, Alex Kaethner, Anthony DK Draper, Christian L James, Alice G Mitchell, Jennifer Yan, Anna Ralph and Bo Remenyi
                      Med J Aust 2020; 213 (3): . || doi: 10.5694/mja2.50682
                      Published online: 13 July 2020

                      Abstract

                      Objectives: Using echocardiographic screening, to estimate the prevalence of rheumatic heart disease (RHD) in a remote Northern Territory town.

                      Design: Prospective, cross‐sectional echocardiographic screening study; results compared with data from the NT rheumatic heart disease register.

                      Setting, participants: People aged 5–20 years living in Maningrida, West Arnhem Land (population, 2610, including 2366 Indigenous Australians), March 2018 and November 2018.

                      Intervention: Echocardiographic screening for RHD by an expert cardiologist or cardiac sonographer.

                      Main outcome measures: Definite or borderline RHD, based on World Heart Federation criteria; history of acute rheumatic fever (ARF), based on Australian guidelines for diagnosing ARF.

                      Results: The screening participation rate was 72%. The median age of the 613 participants was 11 years (interquartile range, 8–14 years); 298 (49%) were girls or women, and 592 (97%) were Aboriginal Australians. Definite RHD was detected in 32 screened participants (5.2%), including 20 not previously diagnosed with RHD; in five new cases, RHD was classified as severe, and three of the participants involved required cardiac surgery. Borderline RHD was diagnosed in 17 participants (2.8%). According to NT RHD register data at the end of the study period, 88 of 849 people in Maningrida and the surrounding homelands aged 5–20 years (10%) were receiving secondary prophylaxis following diagnoses of definite RHD or definite or probable ARF.

                      Conclusion: Passive case finding for ARF and RHD is inadequate in some remote Australian communities with a very high burden of RHD, placing children and young people with undetected RHD at great risk of poor health outcomes. Active case finding by regular echocardiographic screening is required in such areas.

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                      • 1 Menzies School of Health Research, Charles Darwin University, Darwin, NT
                      • 2 Royal Darwin Hospital, Darwin, NT
                      • 3 Top End Health Service, Maningrida Health Centre, Maningrida, NT
                      • 4 University of Otago, Dunedin, New Zealand
                      • 5 NT Cardiac, Darwin, NT
                      • 6 Centre for Disease Control, Northern Territory Department of Health, Darwin, NT


                      Correspondence: josh.francis@menzies.edu.au
                      Acknowledgements: 

                      The Pedrino Project (early detection and treatment of rheumatic heart disease in high risk communities using community‐led approaches) is a Menzies School of Health Research project, supported by a Heart Foundation Vanguard Grant and a pilot grant from the National Health and Medical Research Council (1131932: Improving health outcomes in the tropical north: a multidisciplinary collaboration [HOT NORTH]). It was also supported by Rotary Oceania Medical Aid for Children (ROMAC), the Snow Foundation, the Bawinanga Aboriginal Corporation, and the Humpty Dumpty Foundation, and by in‐kind support from NT Cardiac, the Starlight Children's Foundation, Take Heart (Moonshine Agency), the Northern Territory Department of Health, the Maningrida Health Centre, the Northern Territory Rheumatic Heart Disease Control program, the Mala'la Health Board, Maningrida College, the Lurra Language and Culture Unit, and the West Arnhem Regional Council. Anna Ralph is supported by a National Health and Medical Research Council fellowship (1142011).We acknowledge the contributions of Leroy Bading, Lionel Cooper, Madeline Mackey, Lachlan Nicolson, Erin Riddell and Matthew Ryan (West Arnhem Shire Council, logistics); Joyce Bohme, Roderick Brown and Rickisha Redford Bohme (Bawinanga Aboriginal Corporation, logistics); Georgina Byron (Snow Foundation, communications); Abigail Carter, Carolyn Coleman, Joseph Diddo, Laurie Guraylayla, Alistair James, Cindy Jinmarabynana, Nelson Nawilmak, Stanley Rankin, Mason Scholes, Russell Stewart and Karen Wuridjal (Maningrida College, education); Sue Collins and Mike Hill (Moonshine Agency, communications); Laura Francis, Kate Hardie, Lorraine Harry, Kristine McConnell‐King, Karen Shergold, Steven Wilson Dashwood and James Woods (Top End Health Services, logistics); Trudy Francis and Kaya Gardiner (data entry); Debbie Hall (Menzies School of Health, logistics); Kate Johnston, Daniel Milne and Sarah Reuben (Starlight Foundation, participant entertainment); Jo Killmister, Daryll Kinnane and Craig Watkins (Maningrida College, logistics); Chris Lowbridge (Menzies School of Health, graphics); Trephrena Taylor and Lesley Woolf (Mala'la Health Board, logistics); and Corinne Toune and Rhiannon Townsend (NT Cardiac, echocardiography).

                      Competing interests:

                      No relevant disclosures.

                      • 1. Australian Institute of Health and Welfare. Acute rheumatic fever and rheumatic heart disease in Australia (AIHW Cat. no. CVD 86). Canberra: AIHW, 2019. https://www.aihw.gov.au/reports/cvd/086/acute-rheumatic-fever-rheumatic-heart-disease/contents/introduction/arf-rhd-preventable-diseases (viewed Oct 2019).
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